Dakum: Poor Adherence to treatment, quackery fuelling drug-resistant TB

Chief Executive Officer (CEO), Institute of Human Virology, Nigeria (IHVN), Dr. Patrick Dakum, in this interview with STANLEY AKPUNONU, blamed poor adherence to treatment and proliferation of quacks as some of the factors influencing the rise of drug-resistant tuberculosis (TB) in Nigeria. Dakum, an assistant professor in the Department of Epidemiology and Preventive Medicine, at the University of Maryland School of Medicine, Baltimore, United States, also stressed the need to put in place a strategic plan to tackle the menace of TB both at the national and state levels.

What are the major challenges militating against efforts to end tuberculosis?
INCREASING drug resistance is one of the major challenges. Primary resistance means when you get a new infection and the bacteria that infected you is already resistant.

When this happens, we cannot start with normal treatment but have to start with treatment that is available for patients that are drug-resistant. The bulk of the resistance is from incomplete treatment, and it is only a few people that end up completing their treatment.

Every patient needs encouragement and adherence counsellor to work with to ensure that they take their prescribed treatment because what leads to this resistance is a lot of incomplete treatment cycles or treatment from quacks.

Alongside treatment, we have adherence programme for patients that are identified with TB, which will enable them to take the medication to the end. Also, we intensify treatment for those who are already drug-resistant so that they would get well and not transmit the disease to others. If as a country we treat every TB patient properly, then we would crash our TB incidence.

In 2015, Institute of Human Virology, Nigeria (IHVN) screened over 156, 333 people living with Human Immuno-deficiency Virus (HIV) for TB, while 2,594 were given preventive services for TB in the 161 sites that IHVN provided for TB/HIV services. About 1, 309 people living with HIV were treated for TB same year.

IHVN has also tested 71, 414 people, for drug-resistant TB and given treatment to 1, 334 people who have drug-resistant TB. Other things that the institute has done include, training of 764 service providers on DR-TB management and building of a bio-safety level 3 laboratory at the National TB Leprosy Training Centre, in Zaria, Kaduna State, the first of its kind in this part of the world, for diagnosis of multi-drug resistant TB, and other illnesses in the country.

It appears the country still has a long way to go in ending tuberculosis

The government must support the fight against TB with a clear budget. As an institute with limited availability of resources, what we do is to respond in the context of prevention, and capacity building of healthcare workers.

However, the most important thing that we have done was to support the National TB programme, which serves as a coordinating entity for all TB programmes in Nigeria.

We also have a state TB programme across the 36 states plus Abuja. Basically, what we did was to collaborate with the National TB programme to scale up what we call the Pragmatic Management of Drug-Resistant TB; we scaled it up across the whole spectrum of diagnosis.

So far, we have been able to establish 10 TB reference laboratories in the country. We have two national reference laboratories one in Zaria, one at the Nigeria Institute of Medical Research (NIMR), and the six zonal reference laboratories that are located in each geopolitical zone.

We also adopted two models of care in the country and were able to put in place, criteria for determining those that are admitted. Historically, you do not force people to be on admission, when for some reasons, they do not want to be. As long as the case is not severe, they can go to the closest hospital to receive care.

We scaled up the treatment centre to about 28 nationwide, and for a hospital that can manage people around their houses, we have over 300 nationwide. That is what we supported the national programme to do. We also supported the scale-up of Gene Xpert laboratories, where there are specialised machines that can detect Drug-Resistant Tuberculosis (DR-TB) within two hours.

We also supported the country in buying drugs. This support placed thousands of people in treatment. Generally, there are improvements in TB care and they have ramped up efforts to make sure that more cases are discovered.

How impactful have all these interventions been?
From the latest report that we have, the incidence has continued to go down, and things are getting better; there is more access now, drugs are readily available, and the supply chain management system has been strengthened. We now also have more support for sputum transportation. However, more efforts need to be put in because we still have a gap with what the World Health Organisation (WHO) says.

We are creating a lot of awareness and also working with community pharmacists, and patent medicine dealers. When people develop some sort of symptoms, we ask them to refer them to places where they can do TB tests. We are creating a lot of awareness at the grassroots because that is where the people are, and where the patients go based on sub-optimal health-seeking behaviours.

We have done some orientation for them; educating them on symptoms that are suggestive of TB. We make sure they write their name in the register send them to the laboratory while also letting the patients know the treatment is free.

TB is basically caused by bacteria and it is airborne, but depending on your level of immunity, you can just be a carrier. Once the cough is two weeks old and above, we need to be sure it is not TB. There is also a low fever and unexpected weight loss, coupled with night sweat. Once you have these symptoms, the next thing is to have a Gene Xpert test or microscopy test done.

For drug-susceptible TB, we treat for six months, and for drug-resistant TB, we can treat from nine to 12 months depending on whether it is multi-drug resistant or extensive drug-resistant. However, poor drug quality causes drug-resistant TB.

Apart from the Federal Government, state governments and local governments, everybody needs to do something to make more money available for drugs, and also make sure that health facilities are functioning well.

What actually informed IHVN’s interventions?
The institute, a non-governmental organisation, was established in 2004 to address the Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) crisis in Nigeria, through developing infrastructure for treatment, care, prevention and support for people living with HIV/AIDS.

IHVN has expanded its services to other infectious diseases like tuberculosis, malaria and non-infectious diseases, including cancers, and also structured to develop and maintain linkages within and outside the country, in collaborative ways that support the government of Nigeria’s health sector strategic plans.

The institute’s key technical and funding partners include the Centres for Disease Control and Prevention, the Global Fund to fight AIDS, Tuberculosis and Malaria, while the Achieving Control of HIV/AIDS Epidemic through Evidence (ACHIEVE) project is funded by the United States President’s Emergency Plan for AIDS Relief (PEPFAR).

ACHIEVE focuses on Anti-retroviral Treatment (ART) for adult and children, including pregnant women, laboratory diagnosis and tracking of patients’ status, care and support for people living with and affected by HIV/AIDS, as well as monitoring and evaluation of patients’ programme progress.

Other focus areas include Prevention of Mother-to-Child Transmission (PMTCT), HIV Testing Services (HTS), support to Orphans and Vulnerable Children, and Gender-based Violence. As of September 2019, 432,905 patients received care and support for HIV/AIDS, and 314, 975 received ARV drugs and treatment under the project.

IHVN has established a centre, International Research Centre of Excellence (IRCE) to promote Public-Private Partnership (PPP) to promote quality health services, capacity building and research in West Africa.

One of the key objectives of the centre of excellence is to provide training and engage new researchers in its mentorship programme and also conduct biomedical research focusing on HIV/AIDS, malaria, tuberculosis and non-communicable diseases. IHVN builds the capacity of healthcare providers and ancillary workers across all implementation and research activities.

The IRCE, which would be commissioned on June 25, 2020, is one of the three centres of IHVN that has conducted training and mentoring on global health education, laboratory and research methodology, statistical methods in epidemiology, scientific and medical ethics, and the principles and practice of clinical trials in collaboration with faculty members of the University of Maryland, Baltimore, United States and other international faculty.

The IRCE would provide a common world-class platform for the implementation of research and clinical trials as part of global networks. It will also foster collaborations and synergy between Nigeria’s finest researchers, and their counterparts at international research institutes and universities, and also provide a safety net that protects IHVN and its collaborators from liability, by proactively ensuring that researches conducted at IHVN are under the highest scientific and ethical standards.

IRCE would also provide opportunities for young Nigerian researchers to develop and execute research projects while being mentored by more experienced investigators at IHVN, Nigerian universities, the Diaspora, and international research institutions and universities.

In addition to a clinical trial unit, IRCE will host seven laboratories in one building for the diagnosis of infectious diseases like HIV, drug-resistant tuberculosis, Ebola, Lassa fever. These laboratories are bio-repository, molecular diagnostics, chemistry, hematology and microbiology, clinical pathology, immunology and vaccinology, genomics resource centre, and a proteomics and metabolic laboratories.

We are also looking at how we as an institute can continue to partner with the government in the delivery of healthcare in Nigeria. Implementation with government and other partners is something that we want to be at home with. Routine implementation should not be carried out by implementing partners, but by the government. So, our role is to strengthen them to be able to do that.

We will continue to give technical support and also participate in researches. The goal of the IRCE is to partner with the Nigerian government, and research institutes around the country, especially in universities to support them in areas where they lack capacity, in diagnostics, and also in tools availability. We also bring together, world-class scientists that will work alongside other scientists here in Nigeria, to advance the frontier of science as far as healthcare is concerned.